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0 0 e co/ <br />Page 1 of 9�-�:,, <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br />appropriate pages of this form to report results.for all components tested. The completed form, written test procedures, and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: <br />Bonfare Market #35 1 Date of Testing: 04/18/2013 <br />Facility Address: <br />15 E. Grantline Road, Tracy, CA 95376 <br />Facility Contact: <br />Sean Kapoor I Phone: (408) 933-4422 <br />Date Local Agency <br />Was Notified of Testing: 04/05/2013 <br />Name of Local Agency Inspector (if present during testing): <br />2. TESTING CONTRACTOR INFORMATION <br />11 Comnanv Name: ECO-CHEK Compliance 11 <br />Technician Conducting Test: Nik Zagorov <br />Credentials: ® CSLB Licensed Contractor ® SWRCB Licensed Tank Tester <br />License Type: A License Number: 958763 <br />Manufacturer Training <br />Manufacturer Component(s) Date Training Expires <br />Caldwell Instruments, Inc. Level Change Indicator N/A <br />3. SUMMARY OF TEST RESULTS <br />- . _ - . - <br />/1 <br />■0�■ <br />0■ <br />0000 <br />►1 <br />000 <br />�■ <br />■0 <br />■00 <br />-11OR-1,413 Lq• <br />// <br />000 <br />�■ <br />■000 <br />0000 <br />0000 <br />0 <br />■0�■ <br />0■ <br />0■ <br />0■ <br />■�0■ <br />■0 <br />■0�■ <br />0■ <br />00■ <br />■00 <br />0000 <br />0000 <br />0 <br />■0 <br />■�0■ <br />0000 <br />0000 <br />0000 <br />0000 <br />0000 <br />If hydrostatic testing was performed, describe what was done with the water after completion of tests: <br />Placed in a 330 gallon tank on a trailer and hauled for reuse as test water <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: OV Date: 04/18/2013 <br />In"low <br />11013 <br />